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Journal Article > Study
Mills PD, Watts BV, Hemphill RR. J Hosp Med. 2014;9:182-185.
A suicide attempt by a hospitalized patient is considered a never event. The majority of inpatient suicides occur in psychiatric units, but a prior Joint Commission sentinel event alert suggested that nearly 15% of attempts happen on medical wards. This study reviewed root cause analysis reports of suicide attempts on medical units in the Veterans Health Administration between 1999 and 2012. Fifty cases were identified and five represented completed suicides. Alcohol withdrawal was the most common reason for admission among patients who attempted suicide while hospitalized. The case reviews revealed communication failures, such as lack of discussion about suicide risks or mitigation plans during handoffs to other medical providers, as common contributors to these events. The authors recommend improved staff education, standardized communication for suicide risk, and protocols for appropriate management of suicidal patients. A prior article provided further implementation strategies for avoiding inpatient suicides.